Romiplostim (Nplate®)

OFFICE ADMINISTRATION – SC INJECTION

Indications for Prior Authorization

  • Chronic immune (idiopathic) thrombocytopenic purpura (ITP)

Patients must meet the following criteria for the indication(s) above:

  • Failure/adverse effects from corticosteroids, immunoglobulins, or splenectomy AND
  • Baseline platelet count of less than 30,000/ml

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P&T Committee:

  • All non-FDA approved uses not listed in the approved indications

Dosing:

  • Initial dose 1 mcg/kg once weekly SC
  • Do Not Exceed: 10 mcg/kg weekly SC

Approval:

  • One month initial
  • 6 months provided patient maintains platelet count between 50 and 200 x 109/L

 

Last review date: May 28, 2019